Declaration of Intent to Provide
Full Time Home-Based Instruction in LWSD #414
2017-18 School Year
This statement must be filed annually by September 15 or within two weeks of the beginning of any public school
quarter, trimester, or semester. Send this form to the superintendent of the public school district within which you reside,
or the district that accepts the transfer. Non- residents of the Lake Washington School District (LWSD) must first apply
and be accepted for a Choice Transfer before filing a Declaration of Intent to provide Home-Based Instruction with
LWSD.
A parent who intends to cause his/her child or children to receive home-based instruction in lieu of attendance or
enrollment in a public school, approved private school, or an extension program of an approved private school must file
an annual declaration of intent to do so in the format prescribed below:
I do hereby declare that I am the parent, guardian, or legal custodian of the child(ren) listed below; that said child(ren) is
(are) between the ages of 8 and 18 and as such are subject to the requirements found in chapter 28A.225 RCW
Compulsory Attendance; I intend to cause said child(ren) to receive home-based instruction as specified in RCW
28A.225.010(4); and if a certificated person will be supervising the instruction, I have indicated this by checking the
appropriate space.
Child’s Name
Child’s Age
Child’s Grade
Child’s Neighborhood School
( ) The home-based instruction will be supervised by a person certificated in Washington State pursuant to chapter
28A.410 RCW.
______________________________
Parent / Guardian Name
_______________________________
Parent / Guardian Signature
__________
Date
Street Address: ______________________________________________________________________
City, State Zip: ______________________________________________________________________
Email:__________________________________
Phone:_________________________
The Law - RCW 28A.200.010 Home-based instruction — Duties of parents.
Each parent whose child is receiving home-based instruction under RCW 28A.225.010(4) shall have the duty to:
(1) File annually a signed declaration of intent that he or she is planning to cause his or her child to receive home-based instruction.
The statement shall include the name and age of the child, shall specify whether a certificated person will be supervising the
instruction, and shall be written in a format prescribed by the superintendent of public instruction. Each parent shall file the
statement by September 15 of the school year or within two weeks of the beginning of any public school quarter, trimester, or
semester with the superintendent of the public school district within which the parent resides or the district that accepts the
transfer, and the student shall be deemed a transfer student of the nonresident district. Parents may apply for transfer under
RCW 28A.225.220.
Please send to: LWSD
Attn: Pam Brown
PO Box 97039
Redmond, WA 98073-9739
You may also fax it to 425-936-1325 or email it to [email protected].
5/26/2017